The Missing Safe Practice

摘要

The leadership of St. Mary's Hospital deserves praise for finally beginning to tell its story about the fatal medication error that occurred in 2006.' That said, it is disappointing that a key safe practice is missing.rnIn 2007, I used this very case to propose five rights of care-givers that health care leaders "must consider as an integral part of a fair and just culture when patients are harmed during the process of care." Careful study of the associated issues led to an evidenced-based "Care of the Caregiver" safe practice, released early in 2009 by the National Quality Forum (NQF) in its Safe Practices for Better Healthcare? Developed through a transparent, consensus-based, national process set forth by the U.S. Congress in 2008, this safe practice, among a current total of 34 safe practices, became an endorsed national standard. Yet there is no evidence that Safe Practice 8 has ever been adopted at St. Mary's; it is not cited in the article.